Classification Of Low Back Pain Using Shirley Sahrmann’s Movement System Impairments, An Overview Of The Concept

Contents

1. INTRODUCTION

The reader is advised that the following text is in no way comprehensive and is written only to provide a broad understanding of Movement Impairment Syndromes concepts and their application to the lumbar spine. For a more comprehensive understanding, the reader is directed to the text Diagnosis and Treatment on Movement Impairment Syndromes written by Shirley Sahrmann (2001), other key texts are listed at the end of this text.

The reader is also informed that a 30 minute interview with Shirley Sahrmann and Nottingham University students is attached below and is recommended as an adjunct to this body of text.

Pain arising from the musculoskeletal system is the most common reason for individuals receiving Physiotherapy, 60% are treated for musculoskeletal pain, 25% of those are treated for Low Back Pain (LBP)(Jette and Davis, 1991) making LBP the most common site of musculoskeletal pain (Deyo and Phillips, 1996). LBP affects at least 80% of us at some point in our lives (Freburger et al, 2009). It is the 5th most common reason people visit a Physician in the U.S. Following an episode of LBP, data suggests that full recovery is often not made after a 12 month period of recovery (Croft et al, 1998). Recurrent LBP is also common (Van Dillen et al, 2005).

A lack of evidence for a management strategy to consistently treat the symptoms and disability of LBP (Van Dillen et al, 2005) has led to the argument that one such classification system is required. To date no system has been found to be applicable to all patients with LBP (Riddle, 1998).

Diagnosis and treatment of Movement System Impairments (MSI) is the work of Dr. Shirley A. Sahrmann. Dr. Sahrmann has achieved Bachelor of Science in Physical Therapy, a Masters degree in Cell biology and Physiology, and a Ph. D. in Neurology at Washington University in St Louis. Dr. Sahrmann is a Catherine Worthingham Fellow of the American Physical Therapy Association and is a recipient of the Associations Marion Williams Research Award, the Lucy Blair Service Award, the Kendall Practice Award, the John H.P. Maley Lecture and Mary McMillan Lecture awards. Dr. Sahrmann has been a keynote speaker at the World Confederation of Physical Therapy. 


2. CONCEPTS

Movement Impairment Syndromes

The Movement Impairment Syndromes (MIS) approach or Movement System Impairment (MSI) offers a method of assigning a diagnosis, category and a treatment to patients with musculoskeletal pain. The term diagnosis is described in Webster’s unabridged dictionary as “the act or art of identifying a disease by its signs and symptoms”, diagnosis provides a label to the condition, that label provides characteristics of the condition (Sahrmann, 1998). The use of categories for classification allows the use of diagnostic schemes for treatment programs, a method that paves the way for evidence based practice (Sahrmann, 2001).
Interventions have often been aimed at symptomatic relief, ignoring the cause of tissue irritation. Managing syndromes has proven difficult as diagnosis is often based on symptomatic reporting, rather than objective testing.
The approach follows a logical process, outlined below;


1. DEVELOPMENT OF HYPOTHESIS OF CAUSAL AND CONTRIBUTING FACTORS
2. SPECIFIC AND SYSTEMATIC EXAMINATION TO IDENTIFY THESE FACTORS
3. FORMULATION OF DIAGNOSIS TO DIRECT TREATMENT
4. TREATMENT STRATEGY BASED ON DIAGNOSIS AND CONTRIBUTING FACTORS
5. EVALUATION OF OUTCOMES OF TREATMENT


The diagnostic categories are the names of joint motions. The syndrome is named after the movement or postural alignment where pain is present, for example; lumbar-extension syndrome is pain when the lumbar spine is extended.
Examinations are combinatorial in nature, meaning one test is not singularly diagnostic. Tests verify the presence of a Directional Susceptibility to Movement (DSM) through therapist observation, and contributing factors, such as muscle stiffness, length and strength, and patterns of recruitment and compensatory secondary joint movement.

The Movement System

Movement is the action of an entire system and its component parts; these include muscular, skeletal, neurologic, cardiovascular, pulmonary, and metabolic components. They are all involved in movement impairment syndromes.

Repeated movements and prolonged postures

Sahrmann believes that it is the movement in our daily activities that cause impairment, this may then progress to pathologic abnormalities. This is based on the changes that occur to tissues when subjected to repeated movement and sustained position throughout our daily motions.
Physical Stress Theory presented by Mueller and Maluf (2002) suggests that excessive tissue stress causing injury can occur from 1 or more of the following 3 mechanisms: (1) a high-magnitude stress applied for a brief period, (2) a low-magnitude stress applied for a long duration, and (3) a moderate-magnitude stress applied to the tissue many times. Therefore repeated use may include for example, one hour working at a desk, many years after stopping a similar activity, or performing the same activity every day for many days. When movement deviates from normal, degenerative change may occur, ideal alignment facilitates optimal movement, reducing the likelihood of repeated microtrauma. We can use an automobile to explain this concept, to allow optimal rotation, the wheels need balance and alignment, this ensures both tyres wear evenly with time.

Precision and Balance of Movement

Human beings move in patterns, in the musculoskeletal patient these patterns tend to be exaggerated. Through clinical observation Sahrmann has established the organising principles that best explain the characteristics of these patterns in movement, their contributing factors, and why they cause pain.
Precision and balance in movement is essential to the maintenance and wellbeing of the movement system. Microtrauma to tissue is caused by repeated lack of balanced or precise movements and will ultimately lead to macrotrauma. As a Physiotherapist restoring or maintaining precise movements is elementary to preventing musculoskeletal pain.

Path of least resistance for motion

This is the concept that movement occurs about a path of least resistance. Increased stiffness of one muscle group or joint can lead to compensatory movement at an adjoining muscle group or joint that is less stiff. Relative stiffness or flexibility in a muscle affects the path of least resistance, musculature can be likened to springs, the bigger a muscle is, the stiffer it is, if you were to put them together the least stiff spring will give, this is because a hypertrophied muscle has an increased passive tension.
For example, if your hamstrings are over trained or shortened they may become resistant to movement, thus compensatory movement occurs at the lumbar spine. The major implication is that as the lumbar spine is now subjected to further movement, further stress forces are imposed on the joint and surrounding tissues, thus there is susceptibility for a movement impairment syndrome to occur.

You get what you train

For example, if you train a muscle to be strong, then it will hypertrophy, develop more fibres, and increase in strength. The implication being as movement occurs along a point of least resistance a trained muscle will be more resistant in comparison to its agonist, therefore there will be a Directional Susceptibility to Movement.

Presence of muscle does not mean it is being appropriately used

This is the concept that although we have the muscle, it may not be functioning in the appropriate way it needs to. This has been referred to as “missing in action”. This has implications for the provision of exercises, where it may be assumed that the exercise is having the desired effect on the structures intended, an atrophied muscle is weaker, and therefore other muscles may compensate. This may be linked to the path of least resistance for motion.

Hypermobility

What moves too much can cause pain. It must be noted this does not mean instability, a stable joint can become hypermobile and cause stress on the joint and surrounding tissues. Hypermobility results in tissues moving out of their optimum range. This concept is linked with the patient’s Directional Susceptibility to Movement.


3. ANATOMY

Thorough understanding of the relevant anatomy of the area in question is key to the movement syndrome approach and key to accurate diagnosis and treatment. An overview of the key anatomical features of the lumbar spine will be described here. For a more comprehensive overview of the lumbar spine anatomy please refer to an anatomy textbook.

Lumbar Vertebrae

The lumbar vertebrae are the largest segments of the vertebral column and are characterized by the absence of the foramen transversarium within the transverse process, and by the absence of facets on the sides of the body. Conditions associated with the lumbar vertebrae are osteoporosis, osteoarthritis, stenosis, spondylolisthesis and fractures.
Between each vertebrae sits an intervertebral disc made up of the annulus fibrosus and nucleus pulposus. It allows for movement of the vertebrae, improves joint congruence and reduces the impact of stressful forces. Disc prolapse which can lead to neuropathy and in serious cases cauda equina syndrome.
Another area of articulation is the facet joint. There are two facet joints in each spinal motion segment. Conditions associated with the facet joint are facet joint syndrome and spondylitis. The facet joint guides and limits movement of the spinal motion segment. In the lumbar spine, it protects the motion segment from anterior shear forces, excessive rotation and flexion (Sharma et al, 1995).

Lumbar Ligaments

The ligaments of the lumbar spine help stabilise the spinal column, playing an important role in resisting the forces associated with flexion, rotation and posterior shear (Sharma et al).
The five main ligaments are; Anterior longitundinal, Posterior longitudinal, Intertransverse, Interspinous, Supraspinous, Ligamentum flavum.

Lumbar musculature

The following table identifies the key musculature relevant to lumbar spine movement impairment syndromes. Origin, insertion and muscular action is beyond the remit of this text, the reader is directed to Grays Anatomy for further information.


 Back Musculature
Latissimus Dorsi
Erector Spinae
Multifidus
Quadratus Lumborum
Interspinales
Intertransversarii
Illiopsoas
Abdominal Musculature
External Oblique
Internal Oblique
Rectus Abdominus
Transversus Abdominus


4. RANGES OF MOVEMENT

In this section we examine the alignment and movement of the lumbar spine and pelvis in common positions, looking at what is normal movement and what is impaired.

Normal ROM at the lumbar spine
MOVEMENT MEAN ROM FINAL DEGREES OF MOTION SEGMENTAL ROM
Flexion 56.6⁰ 20-25⁰ 12-20⁰
Extension Highly variable, therefore difficult to establish (max 50⁰)
Lateral Flexion 25⁰ 3-6⁰
Rotation 13⁰ 2-5⁰

 Lspine rom.jpgLspine rot.jpg

Normal ROM at the hip
Movement Mean ROM
Flexion 125⁰
Extension 10⁰
Abduction 45⁰
Adduction 10⁰
Medial Rotation 45⁰
Lateral Rotation 45⁰

Hip flex rom.jpegHip ext rom.jpgHip abdadd rom.jpegHip rotation rom.jpeg

5. ALIGNMENT: NORMAL Vs IMPAIRED

'The majority of spinal dysfunction is the result of cumulative microtrauma caused by impairments in alignment, in stabilization, and in movement patterns of the spine'. (Sahrmann, 2001)

Standing

In the normal standing position there should be a forward convex curve (lordosis) of the lumbar spine of 25-35 degrees. Acquired impairments are either a decreased lumbar curvature resulting in a flat back or an increased lumbar curvature resulting in an increased lordosis.
The causes of a flat back posture (or posterior pelvic tilt) are predominantly overactive hamstrings/ glutes which prevent the pelvis sitting optimally. When the patient has a flat lumbar spine, the flexibility of the hips becomes particularly important. During forward bending, the individual with a flat lumbar spine must immediately flex the hips to avoid excessive flexion of the spine. If this can’t be achieved a pain syndrome may develop.
Causes of excessive lordosis in standing are imbalances in muscle strength and length such as weak hamstrings/ abdominals, or tight hip flexors (psoas). Excessive visceral fat, especially around the abdomen can lead to a lordotic posture. This imbalance can lead to low back pain, especially when the abdominals, which help support the spine, are weakened.

Sitting

In the normal sitting position, the pelvis posteriorly tilts compared to its position in standing. As a result, the lumbar spine alters its anterior curve and becomes flat. When the spine becomes flat, increased pressure is exerted on the disks as compared with the pressure exerted on the disks in the standing position. This is due to the decrease in load placed upon the facet joints in sitting. (Nordin et al 1989).

Impairments in sitting are often as a result of an inadequate match between an individual and the chair. For example, when sitting in a chair and feet do not touch the ground, there is an anterior pull on the pelvis and spine from the unsupported position of the lower extremities, increasing the anterior force on the disc. Alternatively, a tall individual with long tibias will sit in relative lumbar flexion, due to his/her knees being higher than the pelvis.

In summary, sitting can lead to a number of alignment faults other than lumbar flexion. To reduce the risk of these, the patient should sit all the way back in the chair to use the back support. The shoulders should be in line with the lumbar spine, and the hips should be at a 9O-degree angle with the knees.

Flexion- forward bending

Flexion is the movement of the spine that is most commonly used in everyday activities. During normal lumbar flexion, the initial movement is the posterior sway of the pelvis which allows the center of gravity to remain within the base of support. As the hips start to flex, the lumbar spine begins to reverse its inward curve with further hip flexion completing the movement. Woolsey et al (2001) state that the mean motion of lumbar flexion is 56.6 degrees, with the hips activating during 50% of the movement. (One has to remember that the lumbar spine is in 30 degrees of relative extension prior to the movement therefore the actual lumbar spine ROM is 20 degrees).
Impairments of lumbar flexion often contribute to low back pain. Subjects with low back pain have been shown to move more in the lumbar spine than at the hips (Esola et al, 1996).

Extension

Normal lumbar extension results in an increased anterior curve. The reported value for the maximum lumbar extension curve is approximately 50 degrees, though the range is highly variable (Youdas et al, 1995). Functionally, there is not a great need for a large range of extension though certain sports may demand a large range. For example, in gymnastics (though the repeated hyperextension performed by gymnasts is cited as a cause of low back pain and spondylolysis (Oglen et al, 1989)).

Impairments of lumbar extension tend to stem more from specific segmental problems as opposed to a lack of ROM (stiffness). The spinous processes, discs, and facet joints are primary restraints to hyperextension. Thus repeated hyperextension can lead to damage of the interspinous ligaments and has been found to contribute to disc pathologies (Adams et al, 1988). Furthermore, spinal stenosis is relatively common in the individual older than the age of 65 and is another example of a problem associated with lumbar extension.

Rotation

Impairments tend to originate from excessive rotation caused by repetitive rotational movements, often when individuals are sitting at work. The lumbosacral junction is the most vulnerable area to becoming stretched during these activities. Sports such as golf or squash, are common contributors to excessive rotational forces, especially as the feet are planted during these activities.
Furthermore, stiffness or shortness of the oblique abdominal muscles restricts the rotational motion. Some patients may have asymmetry in the appearance of the lumbar paraspinal musculature.

Lateral Flexion

The normal ROM of lateral flexion for the lumbar vertebrae is 6, except for the lumbosacral segment, which has only 3 degrees of lateral flexion, (White et al, 1978). Based on 6 degrees of motion at each lumbar segment, the total motion from LI to SI is approximately 27 degrees. Lateral flexion is associated with rotation of the lumbar vertebrae to the opposite direction- this is a coupled movement.

Due to this coupling, impairment of the motion/alignment of one movement affects the other. For example, ‘if the lumbar spine is misaligned causing it to be rotated to one side, lateral flexion to that side is limited’ (Sahrmann, 2001).


6. SYNDROMES


Sahrmann outlines a number of syndromes to group patients, dependant on the symptoms that they display when undergoing specific testing. These syndromes are descriptive of either the allignment, stress or movement direction that stimulates the patients pain (Sahrmann 1998.) These tests are often more sensitive than specific. Sahrmann suggests that the severity of symptom reproduction with a specific movement, the reduction of symptoms upon movement correction and the consistency with which this happens is all to be considered before allocating patients to a movement impairment syndrome category. With this in mind the examination of the patient consists of a number of tests, that are combinatorial in nature, to confirm/disprove a clinicians diagnosis of a movement impairment syndrome and its contributing factors e.g. muscular weakness or muscular shortening

MIS classification categories

• Extension-rotation 
• Extension
• Rotation
• Flexion-rotation
• Flexion
Syndromes are listed in order of observed frequency in the clinical environment (Van Dillen et al 2001).

Pain problems indicative of extension rotation syndrome

1. Facet joint syndrome 
2. Spinal stenosis
3. Spondylolysthesis
4. Spinal instability
5. Degenerative disk disease
6. Osteoarthritis of the lumbar spine
7. Herniated intervertebral disk
Though these pathological changes will result in a pain response it should be noted that due to the interlinking structure of the spine it is unlikely that one motion segment alone will be affected. Therefore treating the spine as a whole, altering unwanted stresses or maladaptive movements, rather than focussing rehabilitation on a singular motion segment is preferential.

Testing for the syndrome

The assessment process falls into 4 main testing categories: 
1. Movement impairments
2. Alignment; structural variations and acquired impairments
3. Relative flexibility and stiffness impairments
4. Muscle and recruitment pattern impairments

7. EXTENSION-ROTATION SYNDROME

The following tests and explanations have been sourced from Shirley Sahmann’s text 'Diagnosis and treatment of movement impairment disorders' (2001). Find listed below the tests and explanations for the most common movement impairment syndrome (extension-rotation) .

Standing

Tests for classification

Back against the wall:symptoms present in free standing feel relieved when pressing back against a wall, particularly the lumbar region.
Return from forward bending: Patients reporting pain upon return from a forward bend frequently go into lumbar extension prematurely, instead of hip extension followed by gradual lumbar extension. Alteration: Encourage hip extension followed by gradual lumbar extension.
Lateral flexion: considered a test for rotational abnormality. In addition to pain, the origin of the movement and range of movement are also considered during this test. If the patient appears to be hinging at a particular level this is suggestive of a rotation toward the side of bend. The therapist then places a hand above the illiac crest on the offending side and asks the patient to repeat the lateral flexion. If symptoms ease this is considered to be a positive test for rotation.

Tests for contributing factors

Forward bending: May relieve symptoms. Can be considered a sensitive test, not a specific test. During forward bending there is a translation motion within the spine and a neural stretch, the test does not differentiate between the two.
Rotation: The patient rotates to either side while the therapist stabilises the pelvis. Most movement should occur in the thoracic spine however the therapist should ascertain whether there is movement in the lumbar region. Furthermore increased movement on one side when compared with the other is suggestive of a rotated lumbar spine.

Single leg stance

The patient is required to stand on one leg whilst flexing the contralateral hip to 90 degrees. The therapist assesses the patient whilst this is performed looking for lumbar rotation or hip adduction (hip drop).

Supine

Tests for classification

Active hip/knee flexion: Pelvic rotation reproducing symptoms or rotation of greater than 1/2 inch is indicative of an extension rotation syndrome. As confirmation the therapist then stabilises the pelvis during the motion to prevent untoward rotation, symptoms should reduce.
Active hip abduction/adduction: During the first 50% of hip abduction the pelvis rotates toward the moving limb. If this is the period during which the symptoms are reported the therapist stabilises the pelvis and assists the limb into abduction. By removing the rotation within the spine during the motion and/or removing stress from the spine as llliopsoas lengthens the therapist eases symptoms. This is considered to be a positive test.

Tests for contributing factors

Hip flexor length: Positive when there is anterior movement or rotation at the pelvis when the hip is passively extended.

Straight leg raise:The test is considered positive if the patient experiences pain before reaching 60 degrees. Once symptoms are invoked the patient is instructed to completely relax. If symptoms ease this is suggestive of the discomfort being linked to hip flexor activation stressing the spine rather than a neural problem.

Shoulder flexion: shoulder flexion to 180 degrees can result in lumbar extension and bring on LBP.

Side lying

Tests for classification

Nil

Tests for contributing factors

Lateral rotation of the hip joint: test considered to be positive if the hip is laterally rotated but the patient does not achieve this purely by utilising the hip joint.
Hip abduction: Considered to be a positive test when pain is experienced during this motion, this is thought to be as a result of stresses exerted upon the spine by illiopsoas and quadratus lumborum.
Hip adduction: considered to be a positive test if during this movement there is a lateral pelvic tilt and lateral flexion in the lumbar spine.

Prone

Tests for classification

Knee flexion: the test is considered to be positive for an extension rotation syndrome if there is anterior pelvic rotation and relative lumbar extension when completing the motion. Extension rotation syndrome is confirmed if, when the therapist stabilises the pelvis, the movement is repeated and the symptoms are reduced or eradicated.
Hip rotation: If there is pain produced when completing this movement it suggests that when the hip is rotated there are also rotation forces in both the pelvis and the spine. This results in abnormal stresses being placed on the lumbar spine and therefore pain. It is suggested that this lumbopelvic movement is a compensatory mechanism for reduced range in the hip joint. To confirm the diagnosis the therapist stabilises the pelvis and the movement is repeated, symptoms should be relieved. This can occur with either lateral or medial rotation.
Hip extension: The patient is asked to perform hip extension (limited to 10 degrees) whilst the therapist observes whether excessive lumbar extension or rotation is performed. Both sides should be compared to establish whether movement is excessive. Reproducing symptoms is also considered to be a positive test for an extension rotation syndrome. To confirm diagnosis the patient is instructed to complete the movement once again with a pillow under their stomach whilst contracting their abdominal muscles and avoiding contralateral hip flexion.

Tests for contributing factors

Nil

Quadruped position

Tests for classification

Rocking backwards: If the patient is rotated this can often become more apparent when performing backward rocking, a counterforce to the rotation when applied to the spine can alleviate symptoms. In some patients this rotation can be attributed to hip stiffness in flexion, the therapist should also be assessing hip range of movement during the test.
Rocking forwards: This test often increases a patients symptoms, if previous testing has indicated that the patient has an extension rotation syndrome or if the patient has highly severe symptoms this test should not be performed, furthermore this test should not be used as an exercise.
Shoulder flexion: When this test is performed the therapist is looking for spinal rotation. If there is more than 1.5 inches difference in either between either side of the spine the test can be considered as positive for rotation. If symptoms are bought on the therapist should instruct the patient to contract their abdominal muscles and may if required fix the trunk. The therapist should remain aware of the effect of stabilisation and contraction on the patients symptoms.

Tests for contributing factors

Positional effects: Symptoms are usually minimal in this position due to the increased base of support and minimal loading.

Sitting position

Tests for classification

Positional effects: refer to previous information regarding normal alignment in the sitting position.
Knee extension: the patient is asked to perform knee extension in unsupported sitting, a positive test is where rotation of the lumbar spine is felt by the therapist who has a hand on the lumbar spine on the side that knee extension is being performed. Symptoms should not change unless there is a neural component, in which case the patient is instructed to halt at the point of worsening symptoms.

Tests for contributing factors

Nil

Walking

Gait: The patient is asked to walk whilst the therapist observes, looking for excessive extension in the lumbar spine, especially from stand to toe off and excessive rotation of the pelvis (normal 8 degrees) If this is evident in the patient and they report and increase in symptoms, they should be instructed to engage their abdominal muscles and place their hands just above the illiac crests to control rotational movement.


8. ALIGNMENT- STRUCTURAL VARIATIONS AND ACQUIRED IMPAIRMENTS

Tests for classification

Paraspinal asymmetry: Considered to be positive if there is a one inch difference between the musculature on either side of the lumbar region.
Tests for contributing factors
Lumbar lordosis : Test to be completed if the patient states that they have pain in standing and also have a lordotic lumbar spine, displaying these symptoms is considered to be positive for an extension syndrome. The patient is instructed to press their lumbar spine into a wall, the patient may flex at the hip/knees to achieve this and may also require to move their feet forwards. Symptoms should be relieved.
Thoracic kyphosis: can be associated with lumbar lordosis. Standing against a wall should again be performed, the therapist looking for the shoulders and upper back to be away from the wall.

9. HIP JOINT

The hip joint plays a major role in the presence of low back pain. In fact Sahrmann estimates through personal experience that the hip plays a part in almost all mechanical low back pain. She indicates that around 50% of those presenting with hip problems are due to structural anomaly, these may include; coxa valga, coxa vara, femoral retroversion, femoral anteversion, or femeroacetabular impingement. It is also important to consider muscle length, strength, and stiffness at the hip.


Supine position: When lying with hips and knees extended pain is considered to be a positive finding for lumbar extension rotation syndrome. The patient must be passively moved into hip flexion, ensuring that the entire lower quadrant is relaxed to prevent stresses being exerted on the spine by the hip flexors which could stimulate pain. Symptom reduction in this passively flexed position is considered to be a positive sign of extension.
Side lying: the lumbar spine can be in lateral flexion in this position. Experiencing symptoms in side lying can be considered as a positive test. Rolling a towel and placing it underneath the patients waist can alleviate this.
Prone: patients experiencing pain in this position can be considered to have an extension syndrome. To remedy this the therapist should place a pillow underneath the patients stomach to bring the spine and pelvis into a more neutral position. This should alleviate symptoms.
Sitting position: A positive test is symptoms with extension in the lumbar spine. There are 3 factors of which therapists should be aware, firstly if a patient has thoracic kyphosis this can cause them to hold their lumbar spine in extension. Secondly if the patient is short their feet may not touch the ground in sitting, resulting in anterior rotation of the pelvis. Finally the patient may demonstrate a lordotic curve when in sitting, in this case the patient should be supported in the neutral lumbar position.

10.RELATIVE FLEXIBILITY AND STIFFNESS IMPAIRMENTS

The lumbar spine is excessively flexible into extension and rotation, Sahrmann (2001). The following influence flexion and extension in the lumbar spine:
1. Hip abductors being stiffer than the lateral abdominals.
2. Abdominal muscles being slacker than the hip flexors.
3. Lat dorsi being stiffer than the abdominal muscles, these flatten the lumbar spine by tilting the pelvis posteriorly.
4. The abdominal muscles (responsible for controlling rotation around the pelvis) being less stiff than the TFL.

11. MUSCLE AND RECRUITMENT PATTERN IMPAIRMENTS

Therapists should be aware of dominant muscle group recruitment during functional movements such as stand to sit, sit to stand, leaning forward or going from lying to sitting. Particular attention should be paid to muscle groups such as the hip flexors and the abdominals.

12. TREATMENT

Treatment should be an active process, and not passive. Patients should be given exercises to take away and perform themselves allowing for independent management.

Tests that reproduce the patients symptoms become the treatment intervention, once the stress/movement/alignment fault is corrected. It should be reinforced to the patient that when performing the exercises no symptoms should be brought on. Patients should be made aware that exercises causing discomfort should be removed from the treatment regime until the next contact with a physiotherapist.

We must correct someone's movement pattern, and not just the limitation to that pattern. E.g. if we have overactive hamstrings, compensatory movement may occur at the lumbar spine during forward bending. Reducing overactivity in the hamstrings will not solve the issue, as now the lumbar spine is lengthened. We must consider both what's limiting the movement (hamstrings) and the poor precision and lack of balance in the movement pattern.

13. EVIDENCE

Introduction

The following literature has been reviewed and critiqued using guidance from Greenhalgh (2010) to highlight the available evidence behind the Movement System Impairment Syndromes theory established by S. Sahrmann (2001). Each article will be summarised identifying the “take home message” to the reader and strengths and limitations of the evidence will be defined.


PAPER 1

Trudelle-Jackson, E., Sarvaiya-Shah, S. and Wang, S (2009) Interrater reliability of a movement impairment-based classification system for lumbar spine syndromes in patients with low back pain. The Journal of Orthopaedic and Sports Physical Therapy. 38(6):371-376.

Aim

This paper describes a prospective methodological study “to determine the interrater reliability of the movement impairment –based system described by Sahrmann for classifying patients with chronic lower back pain (CLBP), when the system is used by clinicians with varying amounts of clinical experience and formal training.”

Method

24 patients (8 male, 16 females) were recruited consecutively from patients referred to an out-patient pain clinic to undergo a pain management programme for CLBP. The mean age of the group was 43.5 and had experienced symptoms between 20 and 1040 weeks. 

Inclusion Criteria

Patients who had LBP for 12 weeks or more that were admitted to the pain clinic and enrolled onto a pain management programme for CLBP that were not positive in any of the following exclusion criteria.

Exclusion Criteria

• Pregnancy
• Severe kyphosis, scoliosis or spinal stenosis
• History of spinal surgery in previous 3 months
• Scheduled for surgery
• History of more than one surgical procedure on the spine
• Cancer
• Rheumatoid Arthritis
• Ankylosing Spondylitis
• Neurological disease other than nerve root involvement at the spinal level
• Inability to stand and walk without the use of walking aids
• Modified LBP Owestry Disability Questionnaire score greater than 75


Participants were read their rights as human subjects in a study and signed a form of consent in accordance with guidelines founded by The Institutional Review Board at the University of Texas South-western Medical Centre. Two Physiotherapists with different levels of clinical experience received similar amounts of training and practice to evaluate the patients using a standardised evaluation. Examiner 1 had qualified at a university where the movement impairment syndrome classification system had been taught to them via Sahrmanns’s text book and examiner 2 attended a continuing education course on diagnosis and treatment of movement impairment syndrome instructed by Sahrmann and other associates.
Examiners utilised the standardised examination developed by Sahrmann to identify movement impairments of the lower quadrant and identify the direction of treatment. In this paper both examiners separately examined each patient alone. The order of testing by examiner 1 and 2 was determined by a blind draw done by the patient. Each examiner undertook all the standardised examinations in the same order and then recorded which of the 5 lumbar spine diagnostic categories they found the patient to have. No discussion was allowed between examiners after seeing any of the subjects or throughout the study.
Each lumbar diagnostic category that was assigned to patients by the examiners was used in data analysis. Each category established by the examiners was tabulated to display the frequency of occurrence. Kappa statistics were calculated to determine the percentage of each category used and also to account for any results that were due to chance.

Results

Lumbar rotation with extension syndrome was selected for 41.7% of patients by examiner 1 and 37.2% by examiner 2. Lumbar rotation syndrome was selected for 41.7% by both examiners. Lumbar rotation with flexion syndrome was selected for 16.7% by examiner 1 and 20.8% by examiner 2. The lumbar flexion and lumbar extension categories of diagnosis for CLBP were never assigned to patients by either examiner. 
Lumbar rotation with extension syndrome was the most common syndrome to be selected in the study.
There was 75% agreement between the examiners and the calculated Kappa coefficient was 0.61 (P<.001).

Conclusion

This study demonstrated good interrater-reliability of the movement impairment-based classification system for categorising patients with CLBP between 2 Physiotherapists. The difference in experience between the two examiners training levels adds generalisability of findings to other Physiotherapists. The authors state that only a moderate amount of training was required for examiners to be competent at Sahrmann’s standardised examination which is promising for Physiotherapists interested in implementing this approach in practice. The authors observed that the lumbar rotation with extension syndrome was the most common diagnostic category used in the study. This extends findings by Norton et al (2004) and Sahrmann (2002) who studied the diagnosis and treatment of movement impairment syndromes that found this category to be the most frequent especially in those over 55 years of age. There is adequate research supporting the effectiveness of standardised examination to classify LBP into a diagnostic categories however there is a gap in the literature on the effectiveness of treatment in the movement impairment syndrome (MIS) approach, and this should be studied in the future as the main MIS aim is implementing effective treatment.

Strengths

• A power calculation of sample size needed was performed to ensure detection of a significant statistical difference.
• Findings extend those of previous research.
• Participants were studied in “real life” circumstances as they were not just undergoing observation but were referred to the clinic to undergo treatment.
• Inclusion criteria were broad which improves generalisability to the patient population with CLBP.

Limitations

• The sample size was smaller than calculated due to an examiner having to temporarily leave the Pain Clinic during data collection so only 24 participants were recruited.
• Patient characteristics show that 75% of patients were classified as overweight, obese or extremely obese which may have skewed the distribution of results and affected the Kappa value.
• Participants were aware that they were part of a study during their examination. This may have influenced results as patients may have responded differently to examination and each examiner because they knew they were under observation.
• Inclusion criteria were not clearly set out.

PAPER 2

Harris-Hayes, M., Van Dillen, L. and Sahrmann, S. (2005) Classification, treatment and outcomes of a patient with lumbar extension syndrome. Physiotherapy Theory and Practice 21(3):181-196.

Aims

This case report aims to:
1) Describe the use of an examination to identify the movement impairment syndrome of a patient with CLBP, treatment and outcomes of a patient with lumbar extension syndrome.
2) Describe the patients LBP classification directed treatment.
3) Describe long and short-term outcomes related to symptoms and function.


Patient X was referred to a University based Physiotherapy out-patient setting by her Doctor with a medical diagnosis of lumbar spine segmental dysfunction and sacroiliac pain. Patient X was a 40 year old female with a 12 year history of LBP which began after her first pregnancy. Radiological findings showed spina bifida occulta at L5 with the left transverse process of L5 articulating with the superior aspect of the sacrum. On initial assessment patient X’s symptoms were daily intermittent aching and burning pain in the left side of her lumbar spine and she was currently experiencing a “flare up” of LBP. The patient reported pain on sitting, standing and walking and is waking up at least 4 times per night due to LBP. Pain intensity is 9/10.

Previous treatment for LBP
• Corticosteroid injections
• Ant-inflammatory medication
• Exercise and electrotherapy
The patient reported no changes in pain after any of the above interventions.

Method

The patient was read her rights as a human participant in a study and written consent was gained. Sahrmann performed the standardised examination which contains a series of tests to provoke symptoms from her movement impairment syndrome system. When the painful movement (lumbar extension) was identified Sahrmann modified the movement and improved alignment and strategy with manual stabilisation, the patient reported this reduced LBP. The patient was then observed whilst performing functional tasks such as sit to stand and the examiner noticed exaggerated lumbar extension in posture and during activities. Tasks that involved lumbar extension provoked LBP. The diagnosis category assigned to the patient was lumbar extension syndrome. The examiner instructed the patient to carry out the tasks again but with modification to prevent extension and this reduced pain. The patient was then prescribed home exercises focussing on reducing lumbar extension and pain throughout the day such as decompression in sitting by using chair arms to lift some of the body weight as well as postural education such as using abdominal muscles to reduce extension. Pacing was advised and ergonomic advice was given such as lowering chair height at work to allow the patients feet to touch the floor. Treatment was provided 3 times over a 2 month period. Treatment was provided to correct faults in alignment and improve core strength thereon posture by reducing lumbar extension. The exercises were progressed on each visit and the patient was regularly contacted by telephone to monitor symptoms and management.

Outcomes

• Patient reported a reduction in intensity and frequency of LBP after the second session of Physiotherapy.
• Medication prescribed by the patient’s physician is no longer required after the 2 months
• Intensity of pain has reduced:
• On initial assessment: 9/10, at 2 months: 2/10 and 1/10 at 6 months.
• At 6 months after Physiotherapy:
• The patient reported a reduction of pain during standing and walking.
• The patient reported uninterrupted sleep
• The duration and occurrences of LBP episodes had decreased significantly

Conclusion

Classification directed treatment resulted in improved short-term and long-term impairment and functional level outcomes, even in a patient who had spinal mal-alignment. Symptoms of LBP were not completely diminished; Harris-Hayes et al determine that this is due to the patient having mal-alignment of the spine secondary to spina bifida, the chronicity of the LBP and amount of stress over the 12 years that tissues underwent, disabling them to heal. The type of study limits generalisability to the LBP population although it is promising that this classification directed treatment approach was effective in reducing symptoms and improving function and quality of life in an individual who had a complex past medical history (PMH) and even spinal mal-alignment.

Strengths

• Few follow-ups were needed before symptoms were reduced and function was improved which may promote cost effectiveness and waiting lists?
• Interim check-ups were carried out to monitor the frequency of LBP and compliance of the home exercise programme.
• The patient was studied under “real life” circumstances as they were not just undergoing observation but were referred to the clinic to undergo treatment for LBP.
• The patient that underwent classification directed treatment had a moderate amount of medical diagnoses and interventions which gives hope to those with LBP and complex PMH’s.
• Home exercise programme sheets were provided to promote compliance.
• The patient was able to discontinue pain relief medication prescribed 8 days into the report after 2 months of Physiotherapy treatment due to reduced pain.

Limitations

• The type of this study only recruits one patient therefore these outcomes are non generalisable to the wider population of CLBP sufferers.
• Systematic bias has not been avoided as examiners may have selected patient X for the case report because they believed that patient X would respond well to intervention.
• The patient was a full time Physiotherapy Assistant which could have influenced outcomes reported by the patient.
• The patient was aware that they were part of a case report which may have influenced the reported outcomes.
• There was a lack of specific outcome measure e.g. questionnaire to identify progress of LBP after the 2 months treatment.

PAPER 3

Van Dillen, L., Sahrmann, S. and Wagner, J. (2005) Classification, intervention and outcomes for a person with lumbar rotation flexion disorder. Journal of The American Physical Therapy Society 85:336-351.

This case report aims to: 
• Describe the use of the MSI classification system for LBP in the examination and classification of a patient with a recurrent LBP problem.
• Describe the short- and long-term outcomes of a classification-specific management program.

Case study

22 year old male referred to Physiotherapy by his Physician with a diagnosis of lower back strain. PMH was unremarkable; the patient had no spinal or other medical pathology that would limit Physiotherapy treatment. Patient Y had a 2.5 year history of episodic LBP that began with an intense session of racquet ball. Patient Y had been undergoing regular “flare ups” of his LBP and which had been worsening at the time he was referred for Physiotherapy. Patient Y had no previous treatment for his LBP and was taking 200mg ibuprofen following racquet ball sessions for relief which was becoming less effective in reducing pain.

Method

Author 1 conducted a standardised examination on the patient to identify movements and alignments which change the patients’ symptoms. When symptoms were altered during examination primary tests the patient was given response options to choose from which best matched his symptoms which were “symptoms increased”, “symptoms remained the same” or “symptoms decreased”. The patient was asked to report which of these options he was experiencing after 10 seconds of maintaining the position. Information on the symptoms after each test was recorded. The primary test that produced symptoms was then immediately followed by a secondary test which modified the alignment into improved alignment and movement.
After the examination the authors found that the patient had right sided LBP that increased during primary tests that involved trunk flexion, rotation and side flexion to the right. The assigned diagnostic category was lumbar flexion with rotation syndrome. The secondary tests or modifications were carried out to align the spine as close to neutral as possible and reduce pain; this was done by verbal command from the author, manual assistance and contraction of trunk muscles. The patient reported a decrease in symptoms during secondary tests.

Treatment

Patient Y had 4 Physiotherapy sessions over a 3 month period, follow up visits were 2, 6 and 12 weeks after the initial visit. On the initial visit patient Y completed the Owestry Low Back Pain Disability Questionnaire and again 1 year after the initial visit and also filled out a mailed questionnaire on his progress.
Treatment consisted of 3 components:
• Education on tissue injury and repair
• Analysis and instruction on modification of daily activities
• Exercise directed at specific movement impairments

Outcomes

• Symptom location
• One year after the initial visit symptom location has moved from the left upper lumbar and right and left lower lumbosacral region (worse on the right) to the central part of L5/S1 area.
• Symptom intensity
• Average after previous 7 days was 4/10 on initial assessment and 0/10 one year after
• Worst over previous 7 days was 6/10 on initial assessment and 2/10 one year after
• Symptom frequency and duration
• On initial assessment= intermittent, daily persisting most of the day once symptoms were initiated
• One year after= occasional depending on activity levels. Gone within 5 to 10 minutes after symptom provoking activity
• Medication used
• On initial assessment: Ibuprofen after racquet ball
• One year after: discontinued as no longer needed.
• Patient specific activities: racquet ball
• On initial assessment: increased symptoms after 15 minutes, persistent for 2 to 3 days after onset
• Sitting
• On initial assessment: increased symptoms after 30 minutes
• One year after: sat for 100 minutes with only occasional increase in symptoms
• Driving
• On initial assessment: increased symptoms after 30 minutes
• One year after: can drive for 9 hours for 3 days with only a little stiffness and no symptoms
• Sleeping
• On initial assessment: wakes at least twice due to symptoms
• One year after: no interruptions
• Owestry Low Back Pain Disability Questionnaire Score
• On initial assessment: 16%
• One year after: 4%

Conclusion 

Repetition of specific strategies (alignment and movement) during daily activities may result in specific impairments due to recurring stress on the lumbar region that results in LBP. Modification of the strategies and exercises to change contributing factors have helped reduce symptoms, disability and recurrences of LBP for patient Y and educated him on how to self-manage his condition. This report shows that modification of specific strategies from a classification based management programme has positive effects on short and long term patient outcomes. The patient activity outcome identifies that maintaining sporting activities with modified strategies whilst having CLBP is possible and may be of benefit, not of hindrance.

Strengths

• The report states the validity of each specific outcome measure used (NRS, VAS and the Owestry Low Back Pain Disability Questionnaire).
• The duration of follow-up was of adequate length enabling the effect of the intervention to be reflected in the patient outcomes.
• The authors acknowledge that due to the type of study the evidence is not definitive enough to outline a direct link between the interventions applied and the outcomes reported.

Limitations

• There was no mention of formal consent given by patient Y
• Systematic bias may not have been avoided as patient Y may have been selected because authors believed that patient Y would respond well to the intervention.

PAPER 4

Maluf, k., Van Dillen, L. And Sahrmann, S. (2009) Further examination of modyfying patient preferred movement and alignment strategies in patients with low back pain during symptomatic tests. Manual Therapy 14(1): 52-60.

Aim

This observational analytic design of a cross sectional study examines the effect of modifying symptomatic movement and alignment tests in a sample of people with LBP referred to physical therapy.<span style="line-height: 1.5em;" />

Method

Subjects with a LBP related diagnosis who were referred for treatment at a University based Physiotherapy out-patient clinic were recruited consecutively at their initial visit. Patients were given a self-report form to identify if they were positive of any exclusion criteria. 51 subjects were selected.

Inclusion criteria

• Patients aged between 18-75 who were referred for Physiotherapy with symptoms related to a LBP in either the region of the lower back, proximal lower extremity or distal lower extremity.

Exclusion criteria

• Patients with a diagnosis of:
• Spinal stenosis
• Osteoporosis
• Spondylolisthesis
• Rheumatoid arthritis
• Ankylosing Spondylitis
• Patients with spinal fusion
• Severe Kyphosis/scholiosis
• Neurological disease that required hospitalisation
• Patients undergoing treatment for cancer
• Patients with current medical complications of the spine

Signed and informed consent was gained and the study was approved by Washington University Medical School Human Studies Committee.

Examination

Patients were examined on initial assessment by two examiners using a standardised examination. The sequence of primary tests in the standardised examination were randomised to prevent order of effects. 28 primary tests were performed where the patient used their preferred movement or alignment strategy for each primary test. The patient was then asked to report their symptoms after maintaining each test position. When a primary test produced the patients LBP symptoms a secondary test was carried out to modify the movement and ensure spinal alignment is as close to neutral as possible. For each subject the symptoms, modifications of movement and alignment were recorded.

Results

All subjects reported a decrease or complete alleviation of symptoms with one or more of the secondary tests. 82% of patients had reduced pain on 23 of the 28 tests; the 5 tests which patients did not experience a decrease of symptoms were left side lying, quadruped, hip abduction, hip lateral rotation and shoulder flexion in quadruped. On average 52% of subjects reported a decrease in symptoms and 48% reported an elimination of symptoms.

Conclusion

The results of this study suggest that the modifications are generalizable across a number of tests and to a clinically-based sample of patients who have not been treated for their current LBP, and result in a decrease in symptoms in the majority of patients. Furthermore, for many tests there is information attained from the modifications which is important because it can be used to assist in confirming a patient’s classification and therefore, assist in directing treatment and prognosis.

Strengths

• This study adds to literature as it has a larger sample size than preliminary studies (Van Dillen et al 2005; Van Dillen et al 2003) which increases the power and reliability of results as well as generalizability to the LBP population.
• Participants were studied in “real life” circumstances as they were not just undergoing observation but were referred to the clinic to undergo treatment for LBP.

Limitations

• There was incompleteness of follow up as 3% of participants were not included in the study as 9 were unable to provide a response for at least one secondary test and 5 did not schedule sufficient time for the session.
• The patients were aware that they were part of a study which may have influenced the reported outcomes.

ATTACHMENTS

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